=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265794861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID J BRENNEMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2012
-----------------------------------------------------
Last Update Date | 05/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3812 TAYLORSVILLE RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40220-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-451-9949
-----------------------------------------------------
Fax | 502-451-4553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 SPRING FOREST RD STE 130
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-2880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-882-0774
-----------------------------------------------------
Fax | 844-454-0171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 2017-01339
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | ME127465
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 51808
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------